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Screening Strategies to Prevent Aspiration Pneumonia in Acute Stroke

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Pyxis prompt for swallow screenings ... Neurological Assessment including swallow screen module added to EPIC ... Sharing Swallow screening goals with ETC, ... – PowerPoint PPT presentation

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Title: Screening Strategies to Prevent Aspiration Pneumonia in Acute Stroke


1
Screening Strategies to Prevent Aspiration
Pneumonia in Acute Stroke
  • Jeri Lynn M. Braunlin
  • MS CNRN, CNAA, BC, RN, BC
  • Paula Lamb BSN RN

2
The ProblemStroke Complications
  • Pneumonia occurs in 6.7-22 of hospitalized
    patients with stroke
  • Three fold increase in 30 day mortality with
    pneumonia
  • Many pneumonia cases preventable with stroke
    protocols in place
  • Swallow screening
  • Swallow evaluation
  • Diet modifications
  • (Katzan, Dawson, Thomas, Votruba and Cebul,
    2007)

3
Pneumonia and oropharyngeal dysphagia
  • Pneumonia thought to occur most often as result
    of oropharyngeal dysphagia with secondary
    aspiration
  • 42-76 patients with acute stroke develop
    dsyphagia
  • Half will experience aspiration
  • Although not all develop pneumonia
  • (Katzan, Cebul, Husak, Dawson, Baker, 2003)

4
Risk of pneumonia in the stroke population
demographics
  • Older patients
  • Men
  • More likely admitted from a nursing home or via
    the emergency room
  • More co-morbid illnesses
  • Physiologic abnormalities
  • More severe neurologic impairments at admission
  • (Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

5
Ramifications of Pneumonia in Stroke
  • Higher 30 day mortality rates
  • Longer lengths of stay
  • Discharged alive were more likely to require
    extended care
  • More likely to be readmitted to hospital within
    30 days
  • (Katzan,Dawson,Thomas, Votruba and Cebul,
    2007)
  • (Rosenvinge and Starke, 2005)

6
Strategies to prevent pneumonia after stroke
  • Focus to identify at risk patients
  • Swallow screening
  • Modify oral intake
  • Obtain swallow therapy to improve swallow safety
    and dsyphagia
  • (Katsan, Dawson, Thomas, Votruba, Cebul, 2007)

7
The Joint Commission (JC) Performance Measure for
Dysphagia in Acute Stroke
  • A swallow screen for dysphagia should be
    performed on all ischemic and hemorrhagic stroke
    patients before being given food, fluids or
    medications by mouth.
  • www.jointcommision.org

8
JCs rationale for Dysphagia Screening
  • 27-50 of stroke patients develop dysphagia
  • 43-54 of stroke patients with dysphagia will
    experience aspiration
  • Of those patients, 37 will develop pneumonia
  • If not part of a dysphagia diagnosis and
    treatment program, 3.8 with pneumonia will die
  • Other adverse effects include malnutrition and
    increased length of hospital stay
  • www.jointcommision.org

9
Swallow Screen Project Description
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Purpose
  • Increase Dysphagia Screening Rates in Stroke
    Patients

10
Swallow Screening DeficitCause Analysis
  • Inconsistent monitoring, documenting and
    interventions to promote compliance
  • Multiple areas and Caregivers
  • Turnover of Stroke Physician Champion and Stroke
    Educator in consecutive quarters

11
Swallow Screen Solutions
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Development, Implementation and Revision of
    documentation tools.
  • Pyxis prompt for swallow screenings
  • ED Swallow screen added to EPIC (computerized
    medical record system)
  • Neurological Assessment including swallow screen
    module added to EPIC
  • EPIC education r/t documentation times
    (default was timenow which was not necessarily
    the time when the screening was completed)
  • Stroke order sets into Epic

12
Solutions
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Pyxis prompt for swallow screens

13
Emergency Department Swallow Screen
14
Neurological Assessment
15
Stroke Core Measures
16
Swallow Screen Solutions
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Emergency and Trauma Center (ETC) Staff
    education
  • Emergency and Trauma Center Nurse Educational
    Flipcards
  • Hiring of a new Clinical Stroke Program Manager
    who focuses on the Stroke Population
  • Stroke collaboration between care providers -
    Stroke Team and others
  • Revision and Revitalization of the Stroke
    Interdisciplinary Team
  • ETC, ICU and Neuro Unit Staff education
  • Nursing Computer Based Training Module
  • Health Stream - annual competencies)
  • Assignment of a Lead Hospitalist to serve as
    Physician Stroke Champion

17
Current SituationJoint Commission Core Measure
7 Swallow screen prior to any oral medication,
fluids or food
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Rate was 54 at the 2005 certification date
  • Rate has increased to 76 (4th quarter 2006)
  • Rate increased to 83 (Jan-Mar 2007)
  • Rate increased to 88 (April-June 2007)
  • Rate increased to 94 (July-Sept 2007)
  • Rate 91 (Oct-Dec 2007)
  • 2007 yearly average 89

18
Current Situation
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK

Stroke Physician Champion Vacancy
Stroke EducatorVacancy
Stroe Educator vacancy
19
Results
  • Dysphagia Screening rate has increased from 54
    3rd quarter 2005 to 91 in 4th quarter 2007
    (average in 2007- 89).
  • Dysphagia Screening rate has increased from 56
    to 91 following Physician Champion and Stroke
    Educator turnover (an issue 2nd 3rd quarters,
    2006)
  • Aspiration rate was 3.3 in 2006 with increased
    compliance aspiration pneumonia rates have
    decreased to 2.5 in 2007

20
Standardization
  • Instructions
  • Delete sample document icon and replace with
    working document icons as follows
  • Create document in Word.
  • Return to PowerPoint.
  • From Insert Menu, select Object
  • Click Create from File
  • Locate File name in File box
  • Make sure Display as Icon is checked.
  • Click OK
  • Select icon
  • From Slide Show Menu, Select Action Settings.
  • Click Object Action and select Edit
  • Click OK
  • Hiring Stroke Program Manager
  • Staff Education in ETC (Emergency department,
    Neuro unit and ICU
  • Implemented Pyxis prompt and documentation tools
  • Sharing Swallow screening goals with ETC, Neuro
    and ICU Units as well as their respective
    Collaborative Practice Councils, the Professional
    Practice Council, the Organizational Performance
    Improvement Committee, Interdisciplinary Team
    and Stroke Team Members
  • Revised Stroke Physician Orders, Benchmarking
    Guidelines, Patient Education Tools, and
    Instructions for Care at Home.
  • Hospitalist Stroke Champion assignment

21
Future Plans
  • Strive for 100 Dysphagia Screening rate
  • Build Dysphagia Screen monitoring report into
    computerized medical record
  • Continue to monitor pneumonia rates, especially
    aspiration
  • Share Stroke Results with Internal MVH Team
    Members and Success Strategies with Other
    Hospitals

22
Questions and Comments
23
References
  • Adams Jr, Harold P. et al. Guidelines for the
    Early Management of Adults With Ischemic Stroke.
    Stroke Volume 38, Number 5, May 2007,
  • Hinchley, Judith A., Shepard, Timothy, Furie,
    Karen, et. al., Formal Dysphagia Screening
    Protocols Prevent Pneumonia. Stroke. 2005
    361972-1976.
  • Huang, JY, Zhang, Y Yao, et. al., Training in
    Swallowing Prevents Aspiration Pneumonia in
    Stroke Patients with Dysphagia. The Journal of
    International Medical Research, 2006 34
    303-306.
  • Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker
    DW. The Effect of Pneumonia on Mortality among
    Patients Hospitalized for Acute Stroke. Neurology
    2003 25620-625.

24
References
  • Katzen, I. L. , Dawson, N.V., Thomas, M.E., C.
    L., Votruba, M.E., and Cebul, R. D. The cost of
    pneumonia after acute stroke. Neurology
    2007681938-1943
  • Martino PhD, Rosemary, Foley, BSc, Norine, et.
    al., Dysphagia After Stroke. Stroke. 2005
    362756-2763. pg. 275
  • Rosenvinge, Sally K and Starke, Ian D. Improving
    care for patients with dysphagia
  • www.jointcommision.org
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